CDC Objective #5, Define and Develop an Analysis Plan for the Surveillance Data, with location of relevant IHS materials noted in Blue.

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1 1 CDC Objective #5, Define and Develop an Analysis Plan for the Surveillance Data, with location of relevant IHS materials noted in Blue. Comments from Group: Very necessary. All key, especially discussion on denominators and the need to have plan to disseminate and communicate to appropriate audiences and use results. The material in this objective only lightly covered in Level 2 (3 slides located in Day 2 under Data Analysis). IHS Objective #5, Analyze Qualitative Data, could be integrated here. Though it s covered in Level 2, there are more applications in this course. Include review of quantitative vs. qualitative data, qualitative data coding, and surveys from IHS Objective #5. Rest from IHS objective #5 can be left out. Qualitative data can be very important, especially where access to quantitative data is limited. Any discussion of collecting and coding qualitative data should focus less on HOW to collect it (as there are other courses and resources devoted to that), and more on how to integrate both qualitative and quantitative data into surveillance. Session V. Define and Develop an Analysis Plan for the Surveillance Data 1. Calculate frequency and percentage of injury deaths (homicide, suicide, motor vehicle-related, and other unintentional deaths): Level 2 Data Analysis.ppt. Slide 12 (Numeric value). Slide 13 (Proportional distribution). Slide 14 (Population size/volume). Slides (Rates). 1.1 Calculate injury rates: How to Get Appropriate denominators; Level 2 Data Analysis.ppt. Slide 17 (Denominators). 1.2 Calculate crude rates for injury deaths; Level 2 Data Analysis.ppt. Slide 19 (Crude rates). 1.3 Calculate specific rates for injury deaths by age group; Level 2 Data Analysis.ppt. Slide 19 (Specific rates by age). 1.4 Calculate adjusted rates using direct method. Level 2 Data Analysis.ppt. Slide 19 (Adjusted rates). 2. Calculate years of potential life lost (YPLL). Level 2 Data Analysis.ppt. Slide 21 (YPLL). 3. Describe the geographical analysis of data. Billings Injuries as a PH Problem (2).ppt. Slide 4 (Mentions geographic factors important). 4. Define a plan to disseminate and communicate the results; Data Collection Strategies.ppt. Slides 4, 5, 26 (Step 9 in 10-step injury surveillance plan is to develop dissemination plan).

2 4.1 Define the basic elements to include in an injury surveillance system report Recipients Delivery method. 2

3 3 INJURY SURVEILLANCE TRAINING MANUAL PARTICIPANT GUIDE SESSION V DEFINE AND DEVELOP AN ANALYSIS PLAN FOR THE SURVEILLANCE DATA Developed with the support of the National Center for Injury Prevention and Control Division of International Health, Epidemiology Program Office Centers for Disease Control and Prevention Atlanta, GA

4 4 Learning Objectives SESSION V DEFINE AND DEVELOP AN ANALYSIS PLAN FOR THE SURVEILLANCE DATA Calculate injury indicators such as frequencies, percentages, and crude, specific, and adjusted rates. Calculate years of potential life lost (YPLL). Describe the geographical analysis of the data. Define a plan to disseminate and communicate the results. Introduction The analysis and interpretation of surveillance data establishes the foundation for many observational studies, placing surveillance at the forefront of the spectrum of descriptive epidemiology. Surveillance has a myriad of uses such as: to detect epidemics, to suggest hypotheses, to characterize trends in disease or injury, to evaluate prevention programs, or to predict future public health needs. Data from surveillance must be analyzed carefully and interpreted prudently. Data from surveillance systems do not come from a designed study or a randomized trial. Moreover, the analysis (and subsequent interpretation) proceeds from the specific elements of the process in which the assembly of individual units eventually produces a more general picture of health-related conditions in a population. Analysis should be implemented as part of a routine surveillance program. You should keep in mind the following recommendations when analyzing surveillance data: 1 It is tempting to immediately examine trends over time using surveillance data. However, gaining an intimate knowledge of the day-to-day strengths and weaknesses of the data collection methods and the reporting process can provide a real-world sense of the trends that emerge. Although surveillance data are collected individually, one part of the analysis is to have a global image of the problems under surveillance. Proceed from the simplest to the most complex analyses. Begin with questions such as: How many cases were reported by week, month, or year? How many cases were reported by sex? How many cases were reported by age group? These questions must be answered using the surveillance data. 1 Injury Surveillance Training Manual 3 Participant Guide Session V

5 5 In this session you will learn to determine the most common types of analysis for surveillance data. The following indicators will be calculated: Frequency and percentage; Crude, specific and adjusted rates; Years of potential life lost (YPLL). Injury mortality data will be used to calculate measures of frequency and indicators. An introduction to geographical analysis of surveillance data and a plan to disseminate the results are included in this session. 1. Calculate Frequency and Percentage of Injury Deaths (Homicide, Suicide, Motor Vehicle-Related, and Other Unintentional Deaths) Determining frequencies is the first step in the analysis process. The number and percentage of events allow one to describe the size of the problem. The second step is to calculate other kinds of indicators, such as rates, in which the frequency of the event and the affected population are used as well. Rates are presented using a standard denominator, for example, deaths per 100,000 persons, and for a standard time period, often one year. In small populations, several years of deaths may be pooled as the numerator for the rate and person-years of exposure used as the denominator; such rates are often referred to as incident density. Data from an injury surveillance system provide information about the number of cases in a given event. For instance, in El Salvador 2,696 homicides occurred in In Cali, Colombia, in 2002, 1,961 homicides occurred. 3 These data represent just one aspect of the size of the problem. A comparison between these two numbers indicates that the magnitude of the homicide problem is higher in El Salvador than in Cali. The percentage is the proportion of the cases of the total. For instance, in El Salvador, homicides accounted for 44.3% of the total injury deaths. In Cali this proportion was 74.9% (Table 1). Table 1. Injury Mortality in El Salvador and Cali 2000 Cause of Death El Salvador* Cali** Number Percentage Number Percentage Unintentional Deaths Motor Vehicle-Related 1, % % Other Unintentional Deaths % % Violence-Related Deaths Homicides 2, % 1, % Suicides % % Total 6, % 2, % * Injury Surveillance Workshop in El Salvador Data from forensic medicine. ** Fatal Injury Surveillance System in Cali. Data from forensic medicine, district attorney, police department, and transportation office. Injury Surveillance Training Manual 4 Participant Guide Session V

6 6 Simply presenting the numeric value of a data variable is one data analysis method. This method is very common and the information is easy to understand. For example.(consider use of flip chart) One community reported: There were 60 severe injuries (10 fatalities and 50 hospitalizations) due to assault related injuries during Certainly, this information is important to the community. At the very least, it tells you that 10 members of the community were homicide victims and 50 suffered an injury requiring hospitalization. With some simple arithmetic, you can use this information to report approximately 3 homicides per year occur in the community and for every 1 homicide there are 5 assaults resulting in hospitalization. Unfortunately, because of variations in exposure (e.g. population size) the numeric value of one variable cannot be compared to that of the same variable in a different population. For example The occurrence of 10 homicides in a small community is public health problem of a completely different magnitude that the occurrence of 10 homicides in a large city. As a result, numeric values do not indicate risk. IHS Day 2, Data Analysis, Level 2 Data Analysis PPT, Slide 12

7 7 Definition: A proportional distribution, is the percent (i.e., proportion) of the total number of events in a data set which occurred in each of the categories (or subgroups) of that set. Source: Principles of Epidemiology-Statistical Measures used in Epidemiology, CDC Self Study Course Manual 3. Like numeric values, percentages are commonly used, easy to understand, and simple to calculate. For any given data set, the sum of all values must equal 100% Use flip chart to review calculation method. Review with students the terms numerator and denominator. Use flip chart to calculate occupant restraint use from an observational survey. N=227; Yes=68 (30%); No=159 (70%) When data sets are small, percentages can be misleading. N=20; Yes=6 (30%); No=14 (70%) Also like numeric values, percentages are not a measure of risk. IHS Day 2, Data Analysis, Level 2 Data Analysis PPT, Slide 13

8 8 Trigger phrase: comparing apples to oranges This phrase is applicable when comparing the number of injury deaths in different communities without considering population size; or comparing the number of crashes on different roadways without considering traffic volume. To adjust for variations in exposure, like population size or traffic volume, rates are calculated. IHS Day 2, Data Analysis, Level 2 Data Analysis PPT, Slide 14

9 9 Define rate: An expression of the frequency with which an event occurs in a defined population over a specific period of time and converted to a whole number by multiplying to some power of 10 (usually 10,000 or 100,000). Using a flip chart, write the basic formula for a rate (see slide 22) and describe the following: Components of a rate are: numerator (the number of events in a specific time period) denominator (generally the population exposed; sometimes related to other expression of exposure, like traffic volume) and a power of ten IHS Day 2, Data Analysis, Level 2 Data Analysis PPT, Slide 15

10 10 You ve seen rates expressed in many different ways. Here s a simple table that expresses the injury rate for three different communities. Which community has the greater rate? In which community would a person have a greater probability (or risk) of being injured? Let s take a look at the basic calculation of a rate IHS Day 2, Data Analysis, Level 2 Data Analysis PPT, Slide 16

11 11 Describe calculation. Identify sources of denominator (census, tribal enrollment, user population, traffic volume estimates) Remind students that (K) is usually expressed as 10,000 or 100,000. If necessary, relate this piece of the calculation to percentages with a statement like just as we multiply by 100 in calculating percentages, we multiple by 10,000 or 100,000 in calculating rates. Refer to the (same time period) piece of the calculation. Indicate that a common mistake people make when calculating a rate for a multi-year period is that they forget the population should be the combined population for each year. (Consider using a flip chart to elaborate with an example.) For example, the injury death rate for a community for the 3-year period is calculated as: # of cases in # of cases in # of cases in 1992 divided by the population in the population in the population in 1992) times 100,000. IHS Day 2, Data Analysis, Level 2 Data Analysis PPT, Slide 17

12 12 Review calculation. IHS Day 2, Data Analysis, Level 2 Data Analysis PPT, Slide 18

13 13 There are different types of rates. Crude rate: based on the actual number of events in a total population over a given period of time. Example: Injury Death Rate for the whole community. Specific rate: based on the actual number of events in a subgroup of a population over a given period of time. Example: Injury Death Rate for specific age-groups in a community. Adjusted rate: rates constructed to permit fair comparison between groups differing in some important characteristic. Example: Adjusted rates for miscoding of Indian race Example: Age Adjusted rates for variations in age among different populations (Florida adjusted b/c so many retirees; AI/AN adjusted b/c such a young pop) IHS Day 2, Data Analysis, Level 2 Data Analysis PPT, Slide 19

14 14 Some general considerations for rates: The numerate should be accurate that s the number of your cases. The denominator is typically estimated (e.g, population). The denominator isn t always population based. Instead it is some other indicator of exposure, such as vehicle miles or worker hours. Rates are primarily used to compare different groups (like communities) or different subgroups (like age groups within a community). Rates indicate the probability (or risk) of an event (like injury) occurring. IHS Day 2, Data Analysis, Level 2 Data Analysis PPT, Slide 20

15 15 If we have only this information, all we can say is that the number of injury deaths in El Salvador is 2.3 times higher than in Cali, and the percentage of injury deaths due to homicide in Cali is higher than in El Salvador (74.9% vs. 44.3%). Motor vehicle-related deaths and suicides appear to be a bigger problem in El Salvador than in Cali. However, percentages can be deceiving. Comparisons between a city and a country also are not appropriate. The next step is to calculate the rates. Exercise: Calculate frequency and percentage of injuries using local injury data. The first group will calculate frequency and percentage for violence-related deaths (homicide and suicide). The second group will calculate the same indicators for unintentional deaths (motor vehicle-related and other unintentional deaths). 1.1 Calculate Injury Rates: How to Get Appropriate Denominators Rates enable one to make more appropriate, informative comparisons of occurrence in a population over time, among different subpopulations, or among different populations at the same time, since the size of the population and the period of time are accounted for in the calculation of rates. Calculating and analyzing rates is critical in epidemiologic investigations, not only for formulating and testing hypotheses about causes, but also for identifying risk factors for disease and injuries. To determine rates, one must have reliable numerator and denominator data; however, the latter is generally more difficult to obtain in most epidemiologic investigations. 1 A rate measures the frequency of an event in a population. A crucial aspect of a rate is the specification of the time period under consideration. An optional component is a multiplier, such as a power of 10, that is used to convert awkward fractions to more workable numbers. The general form of a rate is shown below: Rate = Number of people injured in a specific period Average or mid-interval population at risk of the event x 10 n The denominator represents the size of the population during the specified time period in which the events occur. The size of n usually ranges from 2 to 6 (i.e., the number at risk varies between 100 and 1,000,000). The selection of n depends on the incidence or prevalence of the event. Many different rates are employed in standard public health practice. These measures are calculated in many ways and may have different connotations. See page 11 for Level 2 Data Analysis PPT Slide #17 5

16 16 Special distinction should be made among the terms rate, ratio, and proportion. A ratio is any quotient obtained by dividing one quantity by another. The numerator and denominator are generally distinct quantities, neither of which has to be a subset of the other. No restrictions exist on the value or dimension of a ratio. A proportion is a special type of ratio for which the numerator is a subset of the denominator population. Although all rates are ratios, in epidemiology, a rate may be a proportion (e.g., prevalence rate). 1 Denominators in Motor Vehicle-Related Injuries To calculate rates for motor vehicle-related injuries, the most common denominator to use is the population affected for city, region, or country. However, other types of denominators can also be useful, such as number of vehicles or number of vehicle miles traveled. The best denominator to use depends on the situation. For instance, to calculate rates of injuries to motorcyclists, the best denominator would be the number of motorcyclists exposed. This is more difficult to obtain than the overall population, but one number that might be available is the number of motorcycles registered in the transportation office. One potential problem with this approach, however, is that the numerator may include injured motorcyclists who are registered in surrounding cities, and thus are not reflected in the denominator. Obtaining an appropriate denominator when you have pedestrians in the numerator is more difficult because statistics on the number of people who walk rather than drive are usually not available. As a nation s economy grows, the number of motor vehicles increases. This means death and injury from road traffic is likely to increase as well, especially if measures are not taken to mitigate the problem. 4 In Table 2, a comparison of the different indicators for motor vehicle-related injuries is shown. Notice how the choice of denominators affects the international comparison. Information about the number of vehicles by country, traveled miles, etc., may be found by visiting Table 2. Indicators for Motor Vehicle-Related Deaths Using Different Denominators Country Vehicles/1,000 Inhabitants Injuries/100,000 Population Deaths/100,000 Population Deaths/10,000 Vehicles Bangladesh Bhutan India Pakistan Sri Lanka United Kingdom United States , Source: Estimating Global Road Fatalities. World Bank, Department for International Development;

17 17 Denominators in Cases of Suicides When calculating rates for suicides, the denominator will usually include the total population. However, some experts believe that children less than 5 years old should be excluded from the denominator because they are not believed capable of understanding the concept of taking one s own life and, therefore, are not capable of committing suicide. Denominators in Cases of Violence-Related Injuries Crude rates often are calculated using the total number of deaths or injuries in the numerator and the affected population in the denominator. Sometimes you will encounter difficulties with available denominator data. For example: If you are using mortality data from a country, the denominator will be the population of this country. However, in some countries population estimates are not available for intercensal years. In some areas, it is difficult to match the geographic area for which injury data is available with the geographic area for which population estimates are available. If you are using injury data from a hospital emergency room, the population in the numerator and denominator could be different. For instance, a trauma hospital may receive cases referred from other hospitals and other cities. Also, residents of the city may go to other hospitals for care. For the denominator, use the population of the city where the trauma hospital is located (if most cases come from the same city). Or, use the city population but exclude nonresidents from the numerator. If most patients are from other cities, try using denominators such as total number of visits to the emergency room for all causes. Then, the indicator will be a proportion, not a rate. 1.2 Calculate Crude Rates for Injury Deaths Computation of crude rates is the initial step in analysis because information about entire populations must be obtained and compared. (See Table 3 to calculate crude rates.) Number of events, in this case, injury deaths in El Salvador. Population at risk, in this case, the population of El Salvador. Ratio, calculated by dividing Column 1 by Column 2. Quotient, calculated by dividing Column 1 by Column 2. Constant used to multiply each result of the fraction; in this case the constant is 100,000. The rate is the final result. It is expressed using per, for instance, 25.9 per 100,000 population, which means that for every 100,000 inhabitants in El Salvador, an average of 25.9 persons have died in motor vehiclerelated events. See page 13 for Level 2 Data Analysis PPT Slide #19 7

18 19 Cause of Death Unintentional Deaths Table 3. Steps to Calculate Crude Rates Using El Salvador Data Number (1) Population (2) Motor Vehicle-Related 1,629 6,276,037 Ratio (3) [(1) / (2)] 1,629 / El Salvador* Quotient (4) Constant (5) Rate per 100,000 (6) [(4) x (5)] 6,276, , / 6,276, , Other Unintentional Deaths 933 6,276,037 Violent Deaths Homicides 2,696 6,276,037 2,696 / 6,276, , Suicides 815 6,276, / 6,276, , Total 6,073 6,276,037 6,073 / 6,276, , * Source: Injury Surveillance Workshop in El Salvador Data from forensic medicine. These data indicate that homicides in El Salvador are the leading cause of injury death. Motor vehicle-related deaths are the second place. The crude world rate for homicide in 1998 was 12.5, the rate in El Salvador is almost 4 times higher. The rate of motor vehicle deaths in the world was 19.9; the rate in El Salvador is clearly higher. Other unintentional deaths in El Salvador have a rate higher than the world rate, which is 7.9 (Table 4). Table 4. Number, Percentage, and Crude Rates of Injury Mortality in El Salvador (2000) and Worldwide (1998) Cause of Death El Salvador* World** Unintentional Deaths Number Percentage Rate per 100,000 Rate per 100,000 Population Population Motor Vehicle-Related 1, % Other Unintentional Deaths % (approximately) Violent Deaths Homicides 2, % Suicides % Total 6, % * Injury Surveillance Workshop in El Salvador Data from forensic medicine. ** Krug E, ed. Injury: A Leading Cause of the Global Burden of Disease. Geneva: World Health Organization;

19 20 Exercise: Using local injury data calculate crude rates for homicide, suicide, and motor vehicle-related and other unintentional deaths. 1.3 Calculate Specific Rates for Injury Deaths by Age Group The rate at which a particular health event occurs may not be constant throughout the entire population. For example, suicides are not considered to affect children under 5 years of age. The risk of dying in motor vehicle crashes increases for teenagers when they are first starting to drive. To examine the differences, the population is partitioned into relevant specific subpopulations, and a specific rate is calculated for each subset. For example, if one calculates death rates by age group, the resulting rates are termed age-specific death rates. Variation of rates among population subgroups results from several factors: natural history of the health problem, differential distribution of susceptibility or causes, and genetic differences among subpopulations. For example, in the United States, injury mortality rates are generally higher among men than women and higher among Blacks than whites. The distribution of subgroups within the population may also be so disparate that the overall rate may not convey useful information. Therefore, the magnitude of an overall rate depends on the magnitude of the rates of the subpopulations as well as on the demographics of the entire population. These variations in rates across a population would remain unknown if only overall rates were calculated. 1 Death rates from injuries vary considerably by age and sex. Awareness of such differences can guide development of programs for prevention among groups at increased risk. For this reason, it is important to have available age- and sex-specific mortality rates for specific injuries. However, the calculation of age- and sex-specific rates requires reasonably accurate information about the composition by age of the population and not just the total number of people at risk. Census data are used to obtain the numbers of individuals in different age and sex groups or strata of the population. Such data may not be available at all or may be available only for selected study populations. In developing countries adult males of working age tend to be at high risk, often because of exposure to environmental (including road traffic) and occupational hazards and, in some countries, to violence. In most countries, the elderly have high mortality rates from non-motor vehicle unintentional injuries and, in some countries, from suicide. Young adult females are at high risk of suicide in the rural areas of some developing countries. 5 See page 13 for Level 2 Data Analysis PPT Slide #19 Injury Surveillance Training Manual 9 Participant Guide Session V

20 21 Age Group (1) The steps necessary to calculate specific rates are shown, using homicide data from Cali, in Table 5: 1. Age groups: distribution by 5-year age groups. 2. Number of homicides in each age group: number of homicides by age group in Cali in Population in each age group: Cali population distribution by 5-year age groups. 4. Ratio (obtained by dividing Column 2 [number of homicides in each age group] by Column 3 [population in each age group]). 5. Quotient (obtained by dividing Column 2 by Column 3). 6. Constant used to multiply each result (in this case, 100,000). 7. The rate is the final result, which means in this case that there were or 190 homicides in the group of year olds per each 100,000 population in this group. Another way to express this result is to say that about 2 out of every 1,000 persons in this age group died by homicide in Cali in Table 5. Specific Rates of Homicide by Age Group in Cali 2000 Number of Homicides (2) Population in Each Group (3) Ratio [(2) / (3)] (4) Quotient (5) Constant (6) Rate per 100,000 Population [(5) / (6)] (7) < ,525 1/208, , ,316 9/214, , ,137 19/197, , , /211, , , /224, , , /193, , , /158, , , /133, , , /96, , , /77, , ,829 53/66, , ,994 31/50, , ,753 17/39, , ,725 26/72, , Total 1,961 1,945,995 1,961/1,945, , Source: Fatal Injury Surveillance Sytem in Cali, Colombia. Data from forensic medicine, district attorney, police department. 10

21 22 Example: Specific rates by age group and sex have been calculated using Cali s homicide data for three different years: 1994, 1997, and In these three years, the specific rates for men have been higher than for women. The age group with highest rates is years of age. Even when the rates decreased, these age groups continued to be the most affected (Figure 1). Figure 1. Homicide Specific Rates by Age and Sex Cali, 1994, 1997, and 2002 HOMICIDE ESPECIFIC RATES BY AGE AND SEX. CALI MALE 300 MALE FEMALE FEMALE 0 < >65 0 < >65 Rate Crude per rate 100,000 per Population population MALE FEMALE 0 < >65 Source: Fatal Injury Surveillance System in Cali, Colombia. Data from: Police, Forensic Medicine, District Attorney, Transportation Office. Injury Surveillance Training Manual 11 Participant Guide Session V

22 Calculate Adjusted Rates Using Direct Method An important use of mortality data is to compare your data with data from other countries or regions. The mortality figures could be different solely because of differences in the distribution of the population by age or other demographic characteristics (e.g., race/ethnicity). Therefore, methods have been developed for comparing mortality in such populations while effectively holding constant characteristics such as age. Two methods of adjustment exist. One method is the direct method of adjustment, whereby a standard population is created, and then the study population s mortality rates are applied to it, stratified by the demographic characteristic(s) of interest (most commonly age). By using a single standard population, we eliminate any possibility that observed differences in rates could be a result of age differences in the two populations. By applying each age-specific mortality rate from the study population to the population in each age group of the standard population, we derive the expected number of deaths that would have occurred in the standard population had those rates been applied. By dividing the total expected numbers of deaths by the size of the standard population, we can calculate the expected mortality rate for the standard population if the study population s age-specific rates have been applied. This adjusted rate represents what the crude rate would have been in the study population if that population had the same distribution as the standard population with respect to the variable(s) for which the adjustment or standardization was carried out. The other method is an indirect adjustment in which the Standardized Mortality Ratio (SMR) is calculated by totaling the observed number of deaths and dividing by the expected number of deaths. Multiplication by 100 is often done to yield results without decimals. The SMR is commonly used in occupational studies. In this manual, adjusted rates are calculated using the direct method of adjustment. The following data must be available to use direct adjustment: 1. Specific rates for the study population; 2. Distribution for the selected standard population across the same strata as those used in determining the specific rates. 1 The steps necessary to calculate adjusted rates are shown in Table 6, using data on homicides in Cali: 1. Age groups; 2. Number of homicides in each age group; 3. Cali population in each age group; See page 13 for Level 2 Data Analysis PPT Slide #19 Injury Surveillance Training Manual 12 Participant Guide Session V

23 24 4. Quotient of number of homicides divided in the population, for each age group; 5. Standard population (this example uses the standard population for the United States in 2000); 6. Expected deaths in each age group, obtained by multiplying the quotient in Column 4 by the standard population in each age group; 7. Adjusted rate is the result of dividing the total of expected deaths by the total of standard population. Number of Homicides (2) Table 6. Adjusted Rates for Homicides in Cali 2000 Cali Population by Age Group (3) Quotient [(2) / (3)] (4) Standard Population (U.S. 2000) (5) Expected Deaths [(4) x (5)] (6) Age Group (1) < , ,987, , ,977,000 2, , ,077,000 65, , ,233,000 62,621 Adjusted Rate for Cali Homicides [Total (6) / Total (5)] per 100, , ,659,000 68, , ,233,000 27, , ,961,000 12, , ,710,000 12,409 Total 1,961 1,945, ,837, , Source: Fatal Injury Surveillance System in Cali, Colombia. Data from forensic medicine, district attorney, police department, and transportation office. In this example, the adjusted rate is lower than crude rate, because the age distribution of Cali s population is different from that of the standard population. Cali has fewer elderly people than the United States. The lower homicide rates among the elderly take on more weight when Cali s rate is adjusted to this older population. Exercise: Calculate adjusted rates using injury local data. You will need a standard population, and the population distribution by age group. 2. Calculate Years of Potential Life Lost (YPLL) YPLL is a measure of the impact of premature mortality on a population. Because of the way in which YPLL is calculated, this measure gives more weight to deaths that occur at younger ages. A specific age is selected as an upper limit. The upper limit is usually the life expectancy in the country, but is sometimes the age at retirement or the age of 75 years. Injury Surveillance Training Manual 13 Participant Guide Session V

24 2 Years of Potential Life Lost or YPLL is another method of data analysis. You all are aware that the burden of injury falls disproportionately on the young. Comparing the total number of injury deaths with deaths from other causes (e.g., cancer, heart disease) can be misleading. It is important to consider how the deaths of so many young affect the future. The effect of this premature mortality is reflected in the measurement of YPLL. YPLL measures the potential life lost for persons between ages 1 and 65 at the time of death. The calculation is simple: 65 age at death. For example: For a person killed in a car crash at age 25, the YPLL is 40; A person who dies of cancer at 60, the YPLL is 5. In 1985 the YPLL for injury in the US was 3,476,752. In comparison the YPLL for cancer was 1,813,245 and for heart disease was 1,600,265. More potential years of life were lost due to injury than due to cancer and heart disease combined. Note: WISQARS allows for YPLL calculation. IHS Day 2, Data Analysis, Level 2 Data Analysis PPT, Slide 21

25 26 The steps to calculate YPLL before 65 years are shown in Table 7 using data from Cali: 1. Distribution by age group of Cali population. 2. Midpoint in each age group, which is obtained by adding the first number in the category plus the second number and dividing by two. For instance, in the age group 25 34, the midpoint is: = 59/2 = (Some methods add 1 to the first part to make the numbers more manageable.) 3. The upper limit in this example is 65, minus the midpoint in each age group. 4. This column shows the number of homicides in each age group. 5. YPLL is calculated by multiplying the number of homicides in each age group (Column 4) by the result in Column 3. Table 7. YPLL by Homicides in Cali, Colombia 2000 Midpoint [Low + High / (2)] (2) Life Expectancy (65) Minus Midpoint (3) YPLL [(3) x (4)] (5) Age Group (1) Homicides (4) = = , = , = , = , = , = NA NA NA NA 85+ NA NA 26 Total 1,961 67,797.5 Adapted from: Establishing an Injury Surveillance System. Instructor s Guide. CDC/Epidemiologic Intelligence Service; Data from: Fatal Injury Surveillance System; Instituto Cisalva, Univalle; Cali, Colombia. The results indicate that in Cali in 2000, homicides accounted for 67,797.5 YPLL. The highest number of YPLL, 34,216, was in the group of year olds. Exercise: Calculate YPLL using injury local data. 3. Describe the Geographical Analysis of Data Maps can be used to graphically depict data using location and geographic coordinates. A map provides a clear, quick method for grasping data and is particularly effective for readers who are familiar with the physical area being portrayed. A few popular types of maps that depict incidence or distribution of health conditions are described below. 5 Currently, there are several different Injury Surveillance Training Manual 14 Participant Guide Session V

26 27 Why Injury Prevention? AI/AN injury rate higher than US all races AI/AN s ages 1-44 are greatly affected Injuries are very costly to treat Why Injury Prevention? FIRST, in injury prevention we seek to address injury death rates throughout Indian Country that are much higher than those of the overall U.S. population in some cases 2 to 3 times. There are many issues involved in this, including such factors as personal behavior, community law enforcement, and access to medical care, as well as geographic factors and lifestyles that contribute to injuries in many areas. You ll be seeing more about these and other factors throughout this course. SECOND, AI/ANs ages 1-44 are hugely affected by injury deaths and disabilities. Within this age range, injuries are the largest cause of death and disability. It s only after reaching age 45 that deaths from other conditions like cancer and heart disease exceed injuries. However, it s very important to remember that, when AI/ANs reach age 45, the injury problem doesn t just go away. It remains a strong cause of death and disability among older populations, and in some communities it s still the largest cause. We need to carefully identify the causes, locations and other factors of these injuries, in order to accurately identify prevention measures that effectively address these injury causes affecting different age groups. Please don t misunderstand the third point. We ARE NOT placing more importance on money over people. Quite the opposite our priority is to have enough resources to treat ALL eligible patients for ALL medical conditions. But the treatment of injuries, especially severe injuries, is often very expensive, and is often needed by many injury victims for the rest of their lives. All the hospital stays, surgeries, medications, therapies and other treatments needed for severe injuries can become a major drain on health care budgets. And because IHS, like all other agencies, has a limited annual budget, all the funds used to treat severe injuries reduces the funds available for non-injury treatments. In many Tribal communities, there are often several non-emergent medical conditions that cannot be treated because of a lack of funds, since so much health care money is spent to treat local severe injuries.

27 28 software packages that can be used to create maps. Some are free, like Epi Map, which is part of the Epi Info software package ( However if you do not have the necessary equipment, you can at least prepare a spot map, locating each case on a printed map. Another possibility is to prepare an area map, which uses frequency, percentages, or rates. The following are the most common type of maps: Spot Maps A spot map is produced by placing a dot or other symbol on the map where the injury occurred. Different symbols can be used for multiple events at a single location. Although a spot map is beneficial for displaying geographic distribution of an event, it does not provide a measure of risk, since population size is not taken into account. Area or Chloropleth Map An area map, also called a shaded or chloropleth map, is a frequently used statistical map involving different types of shading, hatching, or coloring to portray range-graded values. Chloropleth maps are useful for depicting rates of injury in specific areas. These maps are actually superior to spot maps because the rates of risk are depicted. Black Spots To assess road traffic hazards, traffic engineers examine the location and other details of individual crashes. In the aggregate, this information helps to pinpoint specific hazards that can often be corrected in a cost-effective manner by straightforward engineering changes. Such data are increasingly being computerized by traffic authorities. In addition, printed crash maps that use colored pins to denote individual events are often maintained to locate black spots, locations with higher than expected crash rates. Unfortunately, studies of black spots are based upon the use of crash data, and these may be subject to a high degree of underreporting. In developing countries, black spots analyses may be especially valuable to address the problem of injuries and deaths involving vehicle occupants, pedestrians, motorcyclists, and bicyclists. In Colombia, for instance, one strategy of the Fondo de Prevencion Vial (NGO) has been to draw a black/yellow star in the street where most pedestrian deaths occur. 6 15

28 29 Example: In the geographical distribution of homicides in Cali for 2001, shown in Figure 2, each dot represents one homicide and marks the place where it occurred. Homicide clusters with specific characteristics in particular areas of the city are highlighted. Figure 2. Homicides in Cali 2001 COLOMBIA A higher proportion of homicides against women 100% of homicides due to firearms High proportion of homicides from stabbing among nonresidents High proportion of homicides among youth using firearms Source: Fatal Injury Surveillance System. Cali Exercise: Identify each type of map each and the information needed to prepare such a map. Injury Surveillance Training Manual 16 Participant Guide Session V

29 30 4. Define a Plan to Disseminate and Communicate the Results Surveillance and communication are processes that provide information for action. Surveillance data must be presented in a manner that facilitates its use for public health action. Effective communication of public health surveillance results presents a critical link in the translation of scientific information into public health practices and policies. Information from the surveillance system must be disseminated to help decision makers understand the implications of the results and to facilitate implementation of public health action. It is important to present the information clearly and to know the intended audience. 1 Surveillance data is not presented in the same way to the general public as it is presented to public health professionals. Dissemination of the results is a one-way process through which information is conveyed from one point to another. Communication is a collaborative process involving at least one sender and recipient. Steps in controlling and directing information dissemination follow: 1 1. Develop the message; 2. Define the audience; 3. Select the channel; 4. Market the message; 5. Evaluate the impact. Following are some suggestions for making the data presentation useful to the public: 7 Present data to the public in an appealing format. Use language the public understands (professional versus public language). Keep it simple: provide only the most important facts. 4.1 Define the Basic Elements to Include in an Injury Surveillance System Report A report is the means by which the results of surveillance are conveyed to all stakeholders. The needs of stakeholders should be considered when making decisions about report design and production frequency. 8 Below is a sample outline you can use to prepare a report of the surveillance system: Injury Surveillance Training Manual 17 Participant Guide Session V

30 31 Injury Surveillance: A 10-Step Plan 1. Define objectives 2. Form a data committee 3. Identify existing data sources 4. Determine strengths and limitations 5. Conduct preliminary data analysis 6. Reevaluate objectives 7. Consider linkages with other data sources 8. Perform validation studies 9. Develop a dissemination plan 10. Tie surveillance to action and funding Source: Injury Prevention and Public Health Christoffel & Gallagher; 1999 Key discussion points: Surveillance is one model for data collection. These 10 steps, although focused on surveillance, are applicable to a number of injury prevention data collection endeavors such as: observational surveys, home risk assessments, focus groups, community surveys/assessments. Today s discussion on data collection with be framed around these 10 steps.

31 32 Step 1: Define Objectives What will be done with the data? What is the purpose? How will injury be defined? What is the case definition? Key discussion points: Data collection requires substantial planning. Part of the planning involves determining your objectives for collecting the data. You should consider the purpose of surveillance and what might be done with the data. (OPEN FLOOR DISCUSSION & SUMMARIZE ON FLIP CHART; DISCUSSION SHOULD GENERATE A LIST WITH A SAMPLE OF THE FOLLOWING:) (pg Christoffel/Gallagher) Understand injury problem well enough to design targeted programs Track progress & monitor trends in the magnitude & distribution of injury Identify new and emerging hazards in a timely fashion Describe injury patterns to justify need for a program Assess the global impact of a program Overview or snapshot of leading causes Determine magnitude/nature of perceived injury problems Better understand injuries at a particular location (hwy, home, school, workplace) Determine health care costs associated with injury Support policy and intervention efforts Marketing and disseminating data Linking data sources There s much to consider in developing you INJURY DEFINITION and CASE DEFINITION

32 33 Step 9: Develop a Dissemination Plan Share with your stakeholders! Choose right format for intended audience. Data committee can help. Some Considerations Summary vs. detailed Narrative, graphs Frequency of production & distribution Electronic, paper Injury Surveillance: A 10-Step Plan KEY POINTS: (See Gallagher pg ) Put the data in the hands of the right people. Different formats are required for different stakeholders. Data and information are not synonymous! Stakeholders include: Providers of the data Target audiences in the community Policy makers in your organization, the tribe, and other influential organizations Effective dissemination of data can lead to: Support for continued data collection Prioritization of injury interventions Implementation of interventions Visibility for the problem of injury and for your program PROVIDE SOME EXAMPLES OF: Studies, Briefing Documents, News or newsletter articles, white-papers, poster presentations PROVIDE COPY OF EXHIBIT 12-4: FRAMING THE DATA (PG 361)

33 34 Sample Outline for an Injury Surveillance System Report: I. Introduction: Brief description of the injury surveillance system, the purpose, related prevention activities, and the objective of the report. II. III. IV. Leading causes of deaths, frequency and proportion, and rank of injuries among all causes of death. Leading causes of injury mortality, frequency, proportion, and crude rates, emphasizing the highest indicators. Leading causes of injury morbidity, if the information is available. V. Years of potential life lost (YPLL). VI. VII. VIII. Cost of injuries, comparing local data if available. If not, you could use data from studies in other places. Priority injuries identified in the region, summarizing those with the highest number, percentage, rate, costs, and YPLL. Recommendations for prevention strategies. This is the most important step, because it helps stakeholders decide what actions to take. Examples: The injury surveillance system in Bogotá publishes a monthly bulletin with data analysis results, recommendations, and evaluation of strategies already implemented. This bulletin is available at Cisalva Institute prepares a report every three months based on data from the fatal injury surveillance system. This report is sent to mass media contacts and stakeholders in the city; it is available at: The injury surveillance system in emergency rooms in El Salvador produces a weekly bulletin of the system: In Nicaragua, the injury surveillance system in emergency rooms has published articles on injury data on its website: Recipients Recipients of the surveillance report could include decision makers. Decision makers include institutions, particularly those providing data to the surveillance system. Recipients of the report could also include: Stakeholders: Government authorities, Law Enforcement Directors, Public Health Directors, Education Institutions Directors, etc.; Forensic Medicine Offices; District attorney offices; Injury Surveillance Training Manual 18 Participant Guide Session V

34 35 Hospitals and emergency departments; Health professionals in the scientific community; Personnel working with the surveillance system; Scientific/academic researchers; Grassroots organizations; Mass media directors Delivery Method The means of delivering reports depends on available resources and equipment. One channel is via a website; however, only people with a computer and Internet access will be able to reach it. The following are some other means you can use to deliver your injury surveillance system report: Health department newsletters; Public service announcements (PSAs); Press releases; Scientific journal articles; Flyers; Periodicals or annual reports; Presentations and exhibits at scientific and stakeholder meetings; Newspapers; Websites. The mass media are important partners for dissemination of injury surveillance data. Information about injuries is always important news in the city. By establishing an appropriate partnership with the mass media, you may be able to publish your results in the newspaper. This can also be a way to get the community involved. The mass media can also benefit from this relationship because the surveillance team can serve as a valuable ongoing local resource, not only for data, but also for opinions on interventions and political implications. Exercise: Answer the following questions: 1. Which information is most important to present to stakeholders? 2. Which indicators would best show the size of the problem? 3. Do you think cost data is important to stakeholders? 4. Should you include recommendations about prevention strategies in your surveillance reports? Injury Surveillance Training Manual 19 Participant Guide Session V

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